WASHINGTON – Having lost their latest war against President Barack Obama's health care overhaul, Republicans must decide how to wage battles that could fan the issue for the 2016 elections.
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Last month's Supreme Court decision upholding the statute's federal subsidies, which help millions of Americans afford health care, shattered the GOP's best chance of forcing Obama to accept a weakening of his prized law. Without that leverage, Obama would likely veto any major changes they'd send him.
They could, however, try sending him veto-bait legislation designed to show voters how they'd reshape the nation's health care system — if only Republicans could agree on what to do.
With the GOP-run Congress back from a July 4 break, here's a look at their problematic path:
Q: REPUBLICANS SAY THEY WANT TO REPEAL AND REPLACE THE HEALTH CARE LAW, BUT HOW WOULD THEY REVAMP IT?
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A: The House has voted over 50 times to repeal all or part of the law. Yet five years after enactment, Republicans have yet to rally behind a replacement plan.
Several GOP lawmakers have introduced bills or vaguely described what they'd prefer. Details vary, but Republicans generally want to weaken federal coverage requirements, such as which procedures must be insured, and give more flexibility to the states. Many also want to cancel the law's requirements that people get policies and that many employers offer coverage to workers — moves Democrats say would wreak havoc on insurance markets and leave millions without coverage.
Q: WHAT'S PREVENTING REPUBLICANS FROM COALESCING BEHIND ONE PLAN?
A: Republican lawmakers face varying political imperatives back home.
Some from strong GOP areas need to worry about satisfying deeply conservative voters, who despise Obama's law. Others from closely divided states don't want to abolish parts of the statute — like its subsidies and other consumer safeguards — that help millions of voters.
And that's just the congressional races. The campaign for the GOP presidential nomination adds more complications.
Several hopefuls are senators and might use the health care issue to distinguish themselves from competitors — perhaps making them less inclined to heed party leaders and back a consensus plan. And the eventual GOP presidential candidate will likely offer their own plan, leaving some congressional Republicans wondering why they'd push a proposal their own nominee's would overshadow.
Republicans also face thorny decisions about their proposals. How far would the measure go? How much would it cost, and crucially, how would they pay for it?
Q: CAN REPUBLICANS EVEN GET A REPLACEMENT TO OBAMA'S DESK?
A: That's unclear. House Speaker John Boehner, R-Ohio, would not commit recently to holding a House vote this year on a GOP alternative.
The Senate presents an additional problem. Republicans have 54 of the chamber's 100 seats, and Democrats might kill any GOP plan by filibuster — procedural delays that can derail legislation lacking 60 votes.
Q: CAN REPUBLICANS GET AROUND THAT?
The Senate can use a streamlined process called reconciliation that prevents filibusters. It would let Republicans pass something with a simple majority of Senate votes.
So far, they've not decided whether to use the accelerated process for a broad health overhaul that Obama would definitely veto, or a narrower bill drawing some bipartisan support that he might sign, like repealing the law's taxes on high-cost insurance and medical devices.
Or they might use it for a different issue, like deficit reduction or a tax overhaul.
Q: WHY NOT USE IT TO REPEAL THE ENTIRE HEALTH LAW?
A: This procedure comes with show-stopping restrictions.
Most significantly, bills using the process must reduce the deficit.
Unfortunately for Republicans, the nonpartisan Congressional Budget Office last month projected that repealing Obama's law would increase deficits by at least $137 billion over the coming decade.
That's because the law's subsidies for lower-earning people, expanded Medicaid coverage and other spending increases are outweighed by its savings. Those include cutting Medicare payments to providers, collecting fees from the pharmaceutical and other health-care industries and raising taxes on higher-income people and others.
That means that to repeal the entire law using the reconciliation process, Republicans would have to find over $137 billion in savings — a major challenge.
Q: CAN'T THEY USE THIS STREAMLINED PROCESS TO SIMPLY REPEAL PIECES OF THE LAW THEY OPPOSE?
A: Yes, but that's also problematic.
Republicans could eliminate the law's subsidies and expansion of Medicaid. That would save money, but also throw millions of Americans off insurance unless the bill also offered alternative aid.
Repealing the mandates for individual and employer-provided coverage — a favorite GOP goal — would cost money because the government collects fines from people and companies who disobey those requirements. Once again, these rules require the bill to reduce the deficit, not increase it.
Do Republicans repeal the law's tax increases? Most would want to, but that would make it harder for their bill to reduce the deficit.
The reconciliation process also forbids provisions not directly aimed at deficit reduction. That could preclude language sought by many Republicans restricting abortion coverage or allowing health insurance sales across state lines.